'No sex' months proposed as fire-break for HIV in worst-affected countries

Two leading HIV researchers say that countries worst affected by HIV should test whether promoting a national month of sex abstinence could slow the spread of HIV, by interrupting the chain of transmission during the primary, highly infectious stage of HIV infection.

Professor Alan Whiteside of the Health Economics and HIV/AIDS Research Division (HEARD) at the University of Kwazulu-Natal and Dr Justin Parkhurst of the London School of Hygiene and Tropical Medicine (LSHTM) say that if mathematical modelling shows the idea to have possibilities, national campaigns to test the hypothesis should follow.

Swaziland is already considering the idea, Professor Whiteside says.

HIV levels are highest in the month to six weeks after infection, before immune responses begin to control the virus. Individuals in this phase of infection may account for anywhere from 10 to 45% of new HIV infections.

Stopping large numbers of recently infected people from passing on the virus for a month could act as a 'fire break', in the same way that trees are chopped down in a forest fire to break the progress of the fire.

Prof. Whiteside and Dr Parkhurst speculate that in addition to universal male circumcision, one reason why Muslim nations have much lower HIV prevalence is because during the fasting month of Ramadan observant Muslims are expected to abstain from sex during daylight hours.

But, while converting people to a religion is not a practical public health strategy, the authors highlight the World Health Organisation’s ‘tobacco-free’ days and suggest that campaigns – even temporary – can reduce risk behaviour across a population.

“Witnessing the national pride and unity shared among citizens in South Africa during the World Cup, I believe community mobilisations can work. This can be a way forward in some of the worst hit communities. This kind of initiative could provide hyper-endemic countries with a one-off, short-term adaptation that is cost-effective, easy to monitor, and does not create additional stigma,” said Alan Whiteside.

“It is difficult to change people’s behavior permanently, but when communities are mobilised to act together, it is not impossible to imagine regular periods of behaviour change shared by whole communities, or even whole countries.

Evidence shows that if all people could do this simultaneously, it would have a greater protective effect than if people try to do it independently. Of course any such effort would need to be designed to suit local contexts and cultures, but this provides another potential strategy in the fight against HIV,” said Justin Parkhurst.

The authors point out that a month of ‘safe sex/no sex’ can also produce easily verifiable data with regards to adherence, evidenced in the number of births occurring nine months after the campaign.

“In light of the continuing high incidence rates across southern Africa, we may find that this kind of novel idea to address the epidemic presents a real opportunity for prevention,” added Whiteside.

They suggest the idea could be adapted for different populations, depending on what is driving the epidemic. Among miners in South Africa, for example, a `no commercial sex` month may be most appropriate. In other contexts, promoting a 'safe sex only' month might be worth trying.

“Permanent monogamy may be a challenging long-term goal for some, but a 'month of monogamy' might be a useful starting point…In hyper-endemic countries policy-makers, populations and politicians are open to new ideas to address the epidemic,” they conclude.